Formulary guidance and transparency from P&T to point of care

Radar On Market Access: Drug Prices Increases Are Expected to Slow

Posted by Angela Maas on Oct 18, 2018

Pharmaceuticals are expected to undergo a 4.92% price increase from 2018 to 2019, according to the recently released July-August 2018 Drug Price Forecast from Vizient. That’s actually a slowing from the 7.61% increase for 2018, AIS Health reported.

The company conducted its analysis using price and volume data from hospital and non-acute facilities participating in its Vizient Pharmacy Program. Among Vizient members, therapeutic classes with the highest spend include many with specialty drugs.

Disease-modifying antirheumatic agents lead the way with an estimated 8.57% increase, followed by the immunomodulatory agents for multiple sclerosis, at 7.33%. According to the report, “Based on the total amount of spend across care environments, the types of molecular entities approved by the FDA, and the investigational products in the development pipeline, it is certain that specialty pharmaceuticals will continue to play an increasingly important role in pharmacy budgeting.”

However, a handful of events have occurred that are helping slow drug price increases, including CMS giving biosimilars a unique reimbursement code and pass-through status, as well as the administration’s initiative to bring down drug prices.

Challenges within the system include the fragility of the pharmaceutical supply chain, which is leading to multiple drug shortages, and novel new medications that launch at very high prices.

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Topics: Industry Trends, Specialty, Market Access, Data & Analytics

Perspectives on Indication-Based Formularies in Part D

Posted by Angela Maas on Oct 18, 2018

The Trump administration continues to take steps aimed at bringing down drug prices. CMS Administrator Seema Verma said in an Aug. 29 memo to Medicare Part D plan sponsors that they can begin using indication-based formularies in contract year 2020, AIS Health reported.

Starting in 2020, "Part D sponsors may utilize step therapy-like requirements within their [prior authorization] to promote cost-effective drug therapy by requiring the use of one formulary drug for a certain indication prior to authorizing coverage of a second drug for that indication," explains the memo.

Experts say there are multiple benefits to using indication-based formularies. According to Andrew Cournoyer, R.Ph., vice president at Precision for Value, plan sponsors will have the "ability to negotiate steeper discounts in the specialty space — not tied into a single rate for utilization of a product across multiple indications."

Plans also will be able "to assign a combination of higher payment and/or lower cost share for a treatment used for a particular indication, where evidence shows that this treatment for that indication is likely to yield a better outcome compared to alternative treatments," says Elan Rubinstein, Pharm.D., principal at EB Rubinstein Associates. In addition, for uses of a drug in which evidence offers worse outcomes compared with alternatives, plans can "assign a lower payment and/or a higher cost share," he adds.

The policy, however, has multiple potential downsides and risks. Cournoyer points out that it won't impact the broader population. And Rubinstein questions "what constitutes sufficient evidence to support preference for one product over another as a matter of policy and benefit design, if there are patient-specific variables such as severity, age, mobility, comorbidities or other matters that should be taken into consideration?"

Rubinstein also suggests that another challenge will be how payers can "verify the correctness of a drug written for a preferred indication."

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Topics: Payer, Specialty, Market Access, Industry Trends

Radar On Market Access: Opinions Vary on MA Plans’ Use of Step Therapy in Part B

Posted by Angela Maas on Oct 16, 2018

While many stakeholders have praised CMS’s move to allow Medicare Advantage (MA) plans to apply step therapy to drugs covered under Part B, others have cautioned that it could result in delays or restrictions in patients accessing much-needed medications, AIS Health reported.

On Aug. 7, CMS issued new guidance allowing MA plans to use step therapy for Part B drugs as of Jan. 1, 2019. The letter also states that those MA plans that also offer prescription drug coverage may use step therapy to have a beneficiary use a drug under Part D before stepping to one under Part B.

Matt Eyles, president and CEO of America’s Health Insurance Plans, praised the administration’s move. He said, “patients and families deserve the prescription drugs they need at a price they can afford. The new CMS policy helps deliver on that promise while also helping to ensure patients continue to have access to safe, effective, and evidence-based care.”

Meanwhile, some groups expressed their concerns. In a letter to HHS Secretary Alex Azar, the American Medical Association said, “The AMA is concerned about the utilization management tools frequently used by PBMs and health plans to control costs, as they often have little clinical basis and can simply be a means of shifting costs in the system. For example, prior authorization and step therapy protocols can create significant barriers for patients by delaying the start or continuation of necessary medical treatment, which can negatively affect patient health outcomes.”

In an Aug. 8 research note, Leerink analysts noted that “pharmaceutical companies could be enticed to offer rebates back to payers and plans in order to gain preferred status at the front of a step-edit or risk losing volume as a second-line or later agent. In turn, these rebates will lower drug costs for Part B MA plans and patients, but also lower pharmaceutical revenues.”

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Topics: Industry Trends, Payer, Specialty, Market Access, Provider

Trends That Matter for Specialty Drug Management

Posted by Matt Breese on Oct 11, 2018

Specialty drugs continue to be a concern for large employers, according to The Large Employers' 2019 Health Care Strategy and Plan Design Survey by the National Business Group on Health (NBGH), AIS Health reported.

NBGH surveyed its corporate members in May and June on what they are doing for 2019. When NBGH asked employers about specialty pharmacy benefit management techniques, respondents selected more aggressive utilization management protocols as the top strategy, with 64% citing this, followed by having employees get specialty drugs through a specialty pharmacy or the specialty department of the health plan or PBM, cited by 58%. At 44%, site-of-care management notched the third top technique.

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Topics: Specialty, Industry Trends, Branding & Marketing, Data & Analytics

Radar On Market Access: Prime’s New Formulary Excludes Many Drugs Just Added in 2018

Posted by Judy Packer Tursman on Oct 11, 2018

Against the backdrop of giant PBMs' megadeals, mid-sized PBMs such as Prime Therapeutics LLC are strategizing to remain competitive. As part of its effort, Prime tells AIS Health it intends to exclude dozens of drugs from its formulary effective Jan. 1 — and most of the drugs being eliminated only entered the market in 2018.
Prime's national NetResults Formulary is eliminating 30 to 35 drugs, for a total of 303 exclusions, for 2019, says David Lassen, Pharm.D., chief clinical officer of the PBM, which is collectively owned by 18 Blue Cross and Blue Shield plans.
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Topics: Industry Trends, Payer, Specialty, Market Access

Radar On Market Access: Once Deal Closes, What’s Next for Cigna/Express Scripts?

Posted by Leslie Small on Oct 9, 2018

On Sept. 17, the U.S. Department of Justice (DOJ) formally approved Cigna Corp.'s acquisition of Express Scripts Holding Co., a move that sets the companies on a path to close their transaction by the end of the year. Once their tie-up is completed, though, Cigna and Express Scripts will be tasked with a new set of challenges, experts tell AIS Health
"I think the greatest challenge will be kind of the integration of different cultures," says Brian Anderson, a principal at Milliman, Inc., noting that Express Scripts is used to functioning as a stand-alone PBM and Cigna as a health insurer.
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Topics: Industry Trends, Specialty, Market Access

Radar On Market Access: Plans Might Tap Utilization Management for Marijuana-Derived Epilepsy Drug

Posted by Leslie Small on Oct 4, 2018

When a pricey, unique medication for two rare forms of childhood-onset epilepsy comes onto the market — which could happen later this year — payers are likely to cover it but will probably subject the drug to prior authorization, experts tell AIS Health.
The drug in question is Epidiolex (cannabidiol), which in June became the first FDA-approved treatment that contains a purified drug substance derived from marijuana. The oral solution, produced by GW Pharmaceuticals plc, is indicated for the treatment of seizures associated with Lennox-Gastaut syndrome (LGS) or Dravet syndrome for patients ages two and older.
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Topics: Industry Trends, Payer, Specialty, Provider, Data & Analytics

Radar On Market Access: Payers Wait for Gilead’s HCV Generics to Hit Market Soon

Posted by Judy Packer Tursman on Oct 2, 2018

Many payers likely are keeping a close eye on how the pharma industry reacts to Gilead Sciences, Inc.'s Sept. 24 announcement that it intends to soon launch steeply discounted generic versions of two of its chronic hepatitis C virus (HCV) drugs. The biopharma company says these generics will become available in January 2019 in the U.S. — a move that PBM Express Scripts Holding Co. describes as a win for payers and patients alike, AIS Health reported. 
According to Gilead, its newly created subsidiary, Asegua Therapeutics, will sell authorized generics of Harvoni and Epclusa "at a list price of $24,000 for the most common course of therapy."
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Topics: Industry Trends, Payer, Specialty, Provider, Data & Analytics

Trends That Matter for 2019 PBMs' Exclusions

Posted by Judy Packer Tursman on Sep 27, 2018

Leading pharmacy benefit managers (PBMs) recently released updates to their 2019 national formularies. As of Jan. 1, Express Scripts Holding Co. will introduce 48 new formulary exclusions in its 2019 National Preferred Formulary (NPF), which the PBM says will help drive out waste, AIS Health reported.

Adam Fein, Ph.D., president of Pembroke Consulting, Inc. and CEO of Drug Channels Institute, notes that Express Scripts, for the first time, excluded products in two specialty categories: HIV antiretrovirals and Factor VIII recombinant products for hemophilia treatment.

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Topics: Specialty, Industry Trends, Branding & Marketing, Data & Analytics

Radar On Market Access: CVS Bid to Lower Drug Launch Prices Sees Pushback

Posted by Leslie Small on Sep 27, 2018

In an effort to pressure drug manufacturers to temper their launch prices for new drugs, CVS Health Corp. is rolling out a program in which drugs that have a price exceeding a certain cost-effectiveness threshold will be excluded from coverage, AIS Health reported.
CVS will let clients refuse to cover drugs that have a price tag of more than $100,000 per quality-adjusted life year (QALY), provided they are not designated as "breakthrough" therapies by the FDA.
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Topics: Industry Trends, Payer, Specialty, Provider, Data & Analytics